progress & impact series -...

PROGRESS &IMPACT SERIES

Focus on South Africa

Country ReportsNumber 8 • October 2013

PROGRESS &IMPACT SERIESCountry ReportsNumber 8 • October 2013

Focus on South Africa

WHO Library Cataloguing-in-Publication Data

Focus on South Africa.

(Progress & impact series – country reports n. 8)

1.Malaria - prevention and control. 2.Malaria - therapy. 3.Malaria - economics. 4.Financing, Health. 5.South Africa. I.GlobalPartnership to Roll Back Malaria. II.Series.

ISBN 978 92 4 150614 4 (NLM classiþcation: WC 765)

© 2013 World Health Organization on behalf of the Roll Back Malaria Partnership Secretariat

All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can bepurchased from WHO Press, World Health Organization, 20 Aýenue Appia, 1211 Geneýa 27, Switzerland (tel.: +41 22 791 3264;fax: +41 22 791 4857; e-mail: [email protected]).

Requests for permission to reproduce or translate WHO publications – whether for sale or for non-commercial distribution –should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html).

The designations employed and the presentation of the material in this publication do not imply the expression of any opinionwhatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area orof its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximateborder lines for which there may not yet be full agreement.

The mention of speciþc companies or of certain manufacturers’ products does not imply that they are endorsed orrecommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors andomissions excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to verify the information contained in thispublication. However, the published material is being distributed without warranty of any kind, either expressed or implied.The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World HealthOrganization be liable for damages arising from its use.

Photo credits | Front coýer and pp. 6, 8, 16, 19, 27, 28, 29, 30, 33, 34, 37, 39, 44, 47, 49, 53, 58, 65, 66, 69, 70: © National Departmentof Health, South Africa | p. 4: © Laurent Bergeron | p. 10: © Peter Morey | pp. 13, 21, 22: © The Global Fund/Jonx Pillemer |p. 51: © The Global Fund/Juda Ngwenya

Enquiries | Roll Back Malaria Partnership Secretariat | Hosted by the World Health Organization | Avenue Appia 20 |1211 Geneýa 27 | Switzerland | Tel.: +41 22 791 5869 | Fax: +41 22 791 1587 | E-mail: [email protected]

Designed by messaggio | Printed in France

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

2

CONTENTS

CONTENTS

Abbreviations............................................................................................................................................................. 5

Acknowledgements.................................................................................................................................................. 7

Foreword .................................................................................................................................................................... 9

Executive summary................................................................................................................................................. 11

Box 1: The extent of malaria in South Africa................................................................................................ 14

I. History of malaria in South Africa: the early years ........................................................................................ 17

II. Malaria control progress since 2000............................................................................................................... 23

a. Malaria control period........................................................................................................................ 24

b. Scaling up control ............................................................................................................................... 24

c. Strengthening the programme towards elimination ..................................................................... 25

Box 2: Interviews with key players in malaria control in the country .............................................................. 28

III. Gearing up a national malaria control programme for elimination .......................................................... 31

a. Management and planning................................................................................................................ 31

Box 3: Cross-border partnerships ................................................................................................................ 34

b. Securing appropriate funding ........................................................................................................... 40

c. Intervention strategies ....................................................................................................................... 44

Box 4: Malaria health promotion from control to elimination......................................................................... 53

d. Impact and cases averted ................................................................................................................. 55

Box 5: Malaria surveillance and response: the crux of a strong elimination programme .................................. 59

IV. Paving the way towards malaria elimination ............................................................................................... 67

V. Conclusion ........................................................................................................................................................... 71

Annex: List of National Malaria Control Programme Partners ....................................................................... 72

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

3

Table of þgures

1. Malaria incidence by province, South Africa, January–December 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . 152. Breakdown of all reported malaria cases (a) and local cases (b) per district in the three malaria-endemic provinces,

South Africa, April 2012–March 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153. Map of South Africa with former divisions (pre-1994) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174. Malaria distribution map for South Africa in 1938 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185. Annual number of malaria cases and associated deaths, South Africa, 1971–2012 . . . . . . . . . . . . . . . . . . . . . 206. IRS spray coverage in KwaZulu-Natal, Limpopo and Mpumalanga, 2005–2012 . . . . . . . . . . . . . . . . . . . . . . . 257. Malaria incidence in endemic provinces during the malaria transmission seasons of 1999/2000 and 2010/2011 . . . . . . . . . 268. South Africa’s progress on the malaria continuum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279. Goal and objectives of South Africa’s 2012–2018 malaria elimination strategy . . . . . . . . . . . . . . . . . . . . . . . 32

10. LSDI intervention districts and outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3511. Incidence of malaria in TLMI intervention districts, 2009–2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3712. Incidence of malaria in MOZIZA intervention areas, 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3913. Domestic and external funding for malaria control and elimination, South Africa, 2007–2012 . . . . . . . . . . . . . . . . . 4114. Malaria elimination costs by province, South Africa, 2012–2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4215. Malaria elimination funding gaps by intervention, South Africa, 2012–2018 . . . . . . . . . . . . . . . . . . . . . . . . 4316. Number of structures sprayed with IRS and operational coverage in the three malaria-endemic provinces,

South Africa, 2000–2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4617. Diagnostic tools used for conÿrming malaria cases, South Africa, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . 4818. Number of ACT treatment courses delivered to the public and private sectors, South Africa, 2008–2012 . . . . . . . . . . . . 5019. Projected number of malaria cases averted annually through IRS, case management and regional control,

South Africa, 2003–2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5720. Active case investigation and detection at facility level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6021. Active case investigation and detection at community level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6022. Investigated cases of malaria among all provinces of South Africa, 2011 and 2012 . . . . . . . . . . . . . . . . . . . . . 6323. Proportion of local, unclassiÿed and imported cases, malaria-endemic provinces, 2011–2012 . . . . . . . . . . . . . . . . . 64

| CONTENTS |

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

4

ABBREVIATIONS

ACD Active case detection

ACT Artemisinin-based combination therapy

AL Artemether-lumefantrine

DDT Dichlorodiphenyltrichloroethane

DHS District health system

GIS Geographic information system

IEC Information, education and communication

IRS Indoor residual spraying

IVM Integrated vector management

KAP Knowledge, attitudes and practices

KZN KwaZulu-Natal

LSDI Lubombo Spatial Development Initiative

MRC Medical Research Council (Durban, South Africa)

NDOH National Department of Health

NHLS National Health Laboratory Service

NMCP National Malaria Control Programme

PCR Polymerase chain reaction

PHC Primary health care

RBM Roll Back Malaria

RDT Rapid diagnostic test

SADC Southern African Development Community

SAMEC South African Malaria Elimination Committee

SP Sulfadoxine-pyrimethamine

TLMI Trans-Limpopo Malaria Initiative

WHO World Health Organization

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

5

South African Malaria Elimination Committee 2012 and partners/advisors (photo from 2013)

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

6

ACKNOWLEDGEMENTS

ACKNOWLEDGEMENTSThis report was prepared under the auspices of the Roll Back Malaria (RBM) Partnershipto help assess progress towards targets set out in the Global Malaria Action Plan and theMillennium Development Goals (MDGs).

The Department of Health in South Africa hereby wishes to commend the sterling efforts of those individualslisted below for compiling the Roll Back Malaria (RBM) Progress & Impact Series report Focus onSouth Africa. It will be an essential reference document to inform the public and key malaria stakeholders onthe status of malaria in South Africa, and on the progress the country has made over the past century, the pastdecade in particular. It also highlights the priorities for eliminating the disease in the coming years.

This report was jointly coordinated and contributed to by Dr Devanand Moonasar (Director for Malaria at theNational Department of Health [NDOH] in South Africa) and Prof. Lucille Blumberg (Deputy Director, NationalInstitute for Communicable Diseases, and chairperson of the South African Malaria Elimination Committee).

Contributors include Prof. Karen Barnes (Division of Clinical Pharmacology, Department of Medicine, Universityof Cape Town); Dr Cornelia Duýenage (Department of Internal Medicine, One Military Hospital, South Africa);Dr Sunday Idongesit Ukpe (Department of Health and Social Serýices, Mpumalanga Proýince); Dr Frank Hansford(formerly Department of Health and Social Serýices, Limpopo Proýince); Ms Lee Baker (Medicines InformationConsultant, Amayeza Information Centre); Prof. Maureen Coetzee (Uniýersity of the Witwatersrand); Prof. LizetteKoekemoer, Dr Basil Brooke, Prof. John Frean and Dr Natalie Mayet (National Institute for CommunicableDiseases); Prof. Daýe Durrheim (Uniýersity of Newcastle, Australia); Mr Philip Kruger (Limpopo Proýincial MalariaControl Programme); Mr Aaron Mabuza (Mpumalanga Proýincial Malaria Control Programme); Mr Bruce Margotand Mr Eric Raswiswi (KwaZulu-Natal Proýincial Malaria Control Programme); Ms Mary Anne Groepe (WorldHealth Organization [WHO], South Africa); Prof. Immo Kleinschmidt (London School of Hygiene and TropicalMedicine); Prof. Rajendra Maharaj, Dr Jaishree Raman and Mr Ishen Seocharan (South African Medical ResearchCouncil [MRC] in Durban).

Our sincere appreciation goes to Ms Natashia Morris (South African MRC, Durban) for contributing to thedocument and for proýiding all its maps, which were subsequently modiþed for the purpose of the publication. Thefollowing ofþcials from the National Department of Health also proýided inputs: Dr Frew Benson, Ms Eunice Bester,Ms Sanelisiwe Milo, Dr Eunice Misiani, Mr John Burns Nawn, Ms Caron ýan Schalkwyk, Ms Ntsieni Ramalwa andMs Mbavhalelo Shandukani. We would like to pay tribute to the following persons, and acknowledge theirsigniþcant contribution to malaria control in South Africa: Dr Dawid Siegfried Annecke (1895–1955); Dr BothaDe Meillon (1902–2000) and Dr Brian Sharp (1952–2007).

An editorial committee made up of Salim Abdulla (Ifakara Health Institute [IHI]), Matthew Lynch (JohnsHopkins University) and Richard Steketee (Malaria Control and Evaluation Partnership in Africa [MACEPA], aprogramme at PATH) has proýided ýaluable help and insightful comments to this report. It also beneþted fromextensive feedback from Eric Mouzin (RBM Partnership Secretariat), Robert Newman (WHO Global MalariaProgramme [WHO GMP]) and his staff, and Georges Ki-Zerbo (WHO Regional Ofþce for Africa).

Laurent Bergeron (RBM Partnership Secretariat) was the production manager of this report, and providededitorial assistance. We thank Michael Reid (RBM Partnership Secretariat consultant) for proofreadingthe manuscript, as well as Marina Gavrioushkina and Prudence Smith (RBM Partnership Secretariat) forsupporting the release and dissemination of the report. The authors are responsible for any errors or omissions.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

7

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

8

FOREWORD

FOREWORDIt gives me great pleasure to write this forewordfor the Progress & Impact Series report Focus onSouth Africa. Malaria is one of the diseases we havebrought under control over the past several decades.This has not been an easy task; it has been achieýedthanks to the committed efforts of many individualsand organizations, most of them mentioned later inthis report, and we laud their efforts.

We þrmly belieýe there is no quick-þx for controllingmalaria; strategies need to be well thought out,practical, systematically and robustly implementedand meticulously monitored. South Africa’sformalized malaria control programme datesback to the 1940s and has focused on mosquitocontrol through indoor residual spraying togetherwith effective treatment and surveillance.Historically, right up until today, we havemanaged to þnance our own malaria controlefforts; this has been one of the major reasonswhy we have been able to sustain the reduction inmalaria cases in South Africa over several decades.

South Africa has managed to turn the tide onmalaria by ensuring the optimal implementationof the World Health Organization’s approýedinterventions, such as indoor residual spraying usingdichlorodiphenyltrichloroethane, parasitologicallyconþrmed diagnosis and treatment usingartemisinin-based combination therapies, healthpromotion and successful cross-border malariainitiatives with neighbouring Zimbabwe andMozambique.For thesereasonswehaýesigniþcantlyreduced the burden of malaria in South Africato WHO’s classiþed pre-elimination leýels.

In doing this, we have also achieved the malariatarget for the Millennium Development Goal (MDG) 6.The data presented in this report are testimony tothis accomplishment.

Having reduced the incidence of malaria inSouth Africa, we are now embarking on a malariaelimination campaign with the goal of zero localtransmission by 2018. This is an ambitious target butone we are conþdent we will achieýe by robustlyimplementing all available tools. The success ofour elimination campaign will depend on effectivepartnerships at country and regional levels topursue our malaria elimination strategies.

Our malaria elimination efforts will not be exclusivelycountry-speciþc. Such efforts will also haýe aregional focus. We will continue working with ourneighbouring countries to ensure there is effectivemalaria control across our borders and within ourcountries. This, we believe, is critical to movingforward the South African and the Southern AfricanDevelopment Community (SADC) malaria eliminationagenda.

Dr Pakishe Aaron MotsoalediHonourable Minister of Health, South Africa

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

9

Ms Precious MatsosoDirector General, Department of Health, South Africa

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

10

EXECUTIVE SUMMARY

EXECUTIVE SUMMARYProgress and impact of malaria control in South Africa at a glance

• South Africa has been able to roll out and sustaineffective malaria control interventions for morethan 70 years, largely through domestic funding.After a major epidemic in 1999/2000, the countryimplemented evidence-based and practicalpolicies that have successfully positioned it toeliminate the disease by 2018.

• The country has a decentralized malariacontrol programme, with the national malariaprogramme at the National Departmentof Health (NDOH) deþning policies andguidelines, and providing technical supportto provinces. Activities occur at a provinciallevel, funded by a dedicated budget throughthe national treasury. Elimination interventionsare focused on cross-border collaborationswith Mozambique, Swaziland and Zimbabwe,integrated vector management, robust healthpromotion activities and a solid activesurveillance programme.

• The national budget for malaria control increasedsigniþcantly between 2007 and 2008, reaching anaverage of US$ 25 million annually between 2009and 2012.

• South Africa enforced malaria control strategiesand implemented critical interýentions:- Indoor residual spraying (IRS) coverage of

targeted structures was 88% on averagein malaria-endemic provinces between 2000and 2012, with about 1.8 million structuressprayed in 2012/2013.

- Rapid diagnostic tests (RDTs) were rolled outnationwide in 2003 and artemisinin-basedcombination therapies (ACTs) introduced foruncomplicated case management subsequentto parasitologically conþrmed diagnosis inKwaZulu-Natal in 2001, in Limpopo in 2004, andin Mpumalanga in 2006.

- Since 2000, all suspected malaria cases havebeen diagnosed using microscopy and/or RDTs.In 2011, 61% and 39% of malaria cases wererespectiýely conþrmed by microscopy and RDT.

- All positive cases are treated within 24 hours,and treatment is only prescribed once casesare conþrmed (not presumptiýely).

- Training is a cornerstone of the malaria controlprogramme: more than 7700 spray operatorswere trained between 2005 and 2012; an aýerageof 500 doctors and nurses are trained eachyear in managing seýere malaria; and regulartraining sessions in malaria case managementare organized for health-care workers.

- South Africa was instrumental in initiatingcross-border malaria initiatives, such asthe Lubombo Spatial Development Initiative(LSDI) through the signing of a trilateralagreement with heads of state in Mozambiqueand Swaziland. These efforts led to furtherreductions in malaria morbidity and mortalityin South Africa.

• Added to continued socioeconomic improvementsin South Africa, the roll-out of malaria controlinterventions and strategies allowed the followingdisease burden reductions:

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

11

- Nationwide, malaria morbidity and mortalitydecreased 89% and 85% respectively between2000 and 2012, from 64 500 to 6847 malariacases, and from 460 to 70 deaths.

- Between 2011 and 2012, local and importedcases decreased by 18% and 24% respectively.In 2012, 69% of reported malaria cases wereimported, and all districts nationwide had lessthan 1 local malaria case per 1000 populationat risk, advancing South Africa another steptowards eliminating the disease.

- Cross-border collaborations had a remarkableimpact in KwaZulu-Natal and Mpumalangawhere malaria cases dropped by 93% (fromabout 54 400 to 3900) in the two provinces takentogether between 1999/2000 and 2010/2011.

- According to estimates based on the 2000malaria outbreaks in KwaZulu-Natal, at least165 000 malaria cases are averted each year in

the three endemic provinces through effectivemalaria control activities.

• The main lesson learned from more than 70 yearsof malaria control efforts in South Africa is that thecountry has been using indoor residual sprayingto decrease the disease burden and effectiveantimalarial drugs over time, adapting its policiesbased on appropriate surveillance data.

• South Africa has developed a malaria eliminationplan, with the goal to end local transmissionby 2018. It is hoped the country will close thefunding gap already identiþed, so that it canstrengthen its human resource capacity, improveits evidence-based research for surveillanceand response, and ultimately realise its malaria-free goal.

| EXECUTIVE SUMMARY |

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

12

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

13

| THE EXTENT OF MALARIA IN SOUTH AFRICA |

Box 1: The extent of malaria in South Africa

Malaria in South Africa at a glance

• South Africa is home to 52 million inhabitants and is divided into 9 provinces and 52 districts.

• Malaria is endemic in the north-eastern parts of the country, in the Limpopo, Mpumalangaand KwaZulu-Natal provinces.

• Malaria transmission is seasonal, occurring from September to May, with a peak in the highrainfall months of December and January.

• The population at risk is approximately 5 million. In 2012, 6847 malaria cases were reported(National Department of Health [NDOH] data), of which 69% were imported cases.

The Republic of South Africa has approximately52 million inhabitants (Statistics South Africa,2011 census) and is divided into 9 provinces and52 districts. Malaria is endemic in the north-easternparts of the country, the Limpopo, Mpumalangaand KwaZulu-Natal provinces along the borders withBotswana, Zimbabwe, Mozambique and Swaziland(see Figure 1). Limited transmission has previouslyoccurred in the North West province along the MolopoRiver. In the province of Gauteng, the economic hub ofthe country, large numbers of imported malaria casesare reported among returning travellers and migrants.

The variable transmission patterns in neighbouringcountries impact differently on malaria in South Africa.Importation of malaria from Namibia, Botswana andSwaziland into South Africa is negligible, as malariatransmission in these countries is at relatively lowlevels. However, malaria originating from Mozambiqueand Zimbabwe contributes to the higher disease burdenin Limpopo and Mpumalanga provinces (see Figure 1).

Overall, the population at risk of malaria infectionis about 5 million (10% of the overall population of

South Africa). Malaria is seasonal, predominantlyoccurring when temperatures are favourable forvector survival, generally from September to Maywith a peak in the rainy months of December andJanuary. Plasmodium falciparum is responsible formore than 90% of malaria infections, with Anophelesarabiensis being the major vector. P. malariae,P. ovale and P. vivax occasionally occur alone or inmixed infections with P. falciparum.

Malaria risk areas are characterized by relativelylow transmission, so the population at risk does notnecessarily develop immunity and, therefore, personsof any age group are at risk of severe malaria.

The high ýolume migration across South Africa’snorthern and eastern land borders places a signiþcantrisk of importation of malaria into South Africa,increasing the subsequent local transmission riskin the receptive areas where malaria vectors arepresent (see Figure 2 on incidence at district level).Between January and December 2012, 69% of allmalaria cases (n=6847) reported were imported,predominantly from Mozambique and Zimbabwe.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

14

Province

District

Reserve

Incidence per 1000 populationat risk

0

<1

1 to <5

≥5

a) Incidence based on all reported cases b) Incidence based on local cases only

Figure 2Breakdown of all reported malaria cases (a) and local cases (b) per district in the three malaria-endemic provinces, South Africa, April 2012–March 2013In 2012/2013, all districts in the three malaria-endemic provinces had less than 1 malaria case per1000 population at risk, advancing South Africa another step towards eliminating the disease. Comparedwith the incidence of all reported cases, the map of zero local incidence per 1000 population at risk hasexpanded by a further two districts (Waterberg in Limpopo and Uthungulu in KwaZulu-Natal).

Source: NDOH, 2013.

Figure 1Malaria incidence by province, South Africa, January–December 2012Of the total 6847 malaria cases (local plus unclassified plus imported) reported in 2012 in South Africa,40% (n=2743) were recorded in Mpumalanga, 29% (n=2017) in Limpopo, 7% (n=489) in KwaZulu-Nataland the remainder in the non-endemic provinces (of which 89% were in Gauteng, all imported cases).

Province

Reserve

Percentage of total cases

≤1%

>1% to 15%

>15% to 25%

>25% to 35%

>35%

0 290 580 km145

Northern CapeEastern Cape

Limpopo

Free State

Western Cape

North West

KwaZulu-Natal

MpumalangaGauteng

BOTSWANAMOZAMBIQUE

SWAZI -LAND

ZIMBABWE

NAMIBIA

LESOTHO

Source: NDOH, 2013.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

15

The malaria ÿeld station opened by the Institute at Tzaneen in 1931. This station developed intothe Siegfried Annecke Institute, which later became the National Institute for Tropical Diseases.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

16

CHAPTER I

HISTORY OF MALARIA IN SOUTH AFRICA:THE EARLY YEARSSouth Africa’s malaria control programme has been able to roll out and sustain eþective controlinterventions for more than 70 years, largely through domestic funding. It adopted and implementedevidence-based and practical policies, leading to signiÿcant reductions in malaria transmission.These successes have enabled the country to prepare for elimination of the disease.

Large parts of South Africa were historically affectedby malaria, with the disease being endemic in thelow-lying parts of Natal and Transýaal. The þrstdocumented disease outbreaks were in Natal (þrstin 1905) and Zululand, spreading as far south asPort St Johns (see Figure 3) on the east coast in 1927and near Pretoria in the early 1930s. During theseearly outbreaks, larviciding was used as a mosquito

control intervention, with quinine used for prophylaxisand treating clinical malaria cases. Although controlinterventions were put in place during the 1930s and1940s, major malaria epidemics were recorded in1939 and 1943. During the 1939 epidemic, more than9300 malaria deaths were reported in the Transvaal.

Figure 3Map of South Africa with former divisions (pre-1994)In 1994, all homelands and the four original provinces (Cape, Natal, Orange Free State and Transvaal)were abolished, and the nine provinces shown in Figure 1 were established.

Source: NDOH, 2013.

Port St Johns

Cape Province

Transvaal

Natal

Orange Free State

Durban

Ulundi

Umtata

Mafikeng Pretoria

Upington

Nelspruit

Cape Town

Polokwane

Kimberley

Mossel Bay

Klerksdorp

East London

Bloemfontein

Johannesburg

Port Elizabeth

Pietermaritzburg

Former provinces

Former homelandsBophuthatswanaCiskeiGazankuluKangwaneKwaNdebeleZululandLebowaQwaQwaTranskeiVenda

NAMIBIA

BOTSWANA

ZIMBABWE

MOZAM-BIQUE

SWAZI -LAND

LESOTHO

0 290 580 km145

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

17

| HISTORY OF MALARIA IN SOUTH AFRICA: THE EARLY YEARS |

Malaria risk categories

Continuous high risk

Serious risk in summer

Moderate risk in summer

Epidemic slight risk

Pretoria LourencoMarques

Durban

Kruger National Park

BECHUANALAND

RHODESIA

LORENZOMARQUES

SWAZILANDUNION OF SOUTH AFRICA

0 75 150

Kilometres

In the mid-1930s, a research experimentdemonstrated that regular weekly space indoorspraying with a pyrethrum/kerosene mix was amore cost-effective malaria prevention interventionthan larviciding. Furthermore, this adult mosquitocontrol measure did not affect water suppliesfor humans or their livestock. Weekly spacespraying with pyrethrum was then rolled out basedon the malaria distribution map issued at the

time (see Figure 4), and by 1941/1942 more than100 000 people were estimated to be protected.This highly signiþcant and innoýatiýe controlmethod led directly to indoor residual spraying(IRS) of houses with long-lasting insecticides afterWorld War II and to the World Health Organization(WHO) Global Malaria Eradication Campaign in the1950s, and is recognized as a major contributionfrom South Africa to malaria control strategies.

Figure 4Malaria distribution map for South Africa in 1938In the late 1930s, continuous high risk of malaria was defined in the eastern coastal region of Nataland serious risk of malaria transmission in summer was mapped all along the borders with Botswana(Bechuanaland at the time), Zimbabwe (Rhodesia), Mozambique and Swaziland.

Source: NDOH and South African Medical Research Council (MRC), 1997.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

18

Dichlorodiphenyltrichloroethane (DDT) – lessexpensive and more effective – was introducedfor IRS in 1945 with dramatic results. From thenon, vector control programmes were widelyimplemented using larviciding and IRS with DDT,and chloroquine replaced quinine for malaria casetreatment. The programme was so successful thata WHO assessment team visited the malariousprovinces of South Africa in 1959 and maderecommendations regarding the elimination of thedisease in the country.

The low incidence of malaria cases resulted in housespraying being discontinued in certain areas, whichled to malaria resurgence in the 1970s. However, thenumber of malaria cases seldom exceeded 4000 untilthe mid-1980s when chloroquine resistance wasdetected in Natal and migration from Mozambiqueincreased due to political instability in that country.This resulted in more than 6000 malaria cases eachyear from 1985 to 1990, with cases exceeding 10 000 in1985 and 1987 (see Figure 5). Once the þrst-line

treatment in Natal was changed to sulfadoxine-pyrimethamine (SP) in 1988, malaria transmissionbrieÿy returned to preýious leýels but rose againin 1993 when chloroquine resistance was detectedin the Transvaal and climatic conditions favouredmosquito breeding.

Pyrethroids replaced DDT for IRS in most provincesin 1996 and growing resistance of the vectors to thisinsecticide resulted in a surge in malaria incidence.With decreased insecticide and treatment efþcacy,as well as with more widespread diagnosis atpublic health facilities, the number of malariacases soared, increasing more than threefold in1996 compared with the previous year, and thenrising to about 64 500 cases in 2000, with about460 deaths recorded. This was rapidly halted bycombining DDT and pyrethroids for malaria vectorcontrol in the three malaria-endemic provinces,and by introducing artemisinin-based combinationtherapy (ACT) in 2001 in KwaZulu-Natal, in 2004 inLimpopo, and in 2006 in Mpumalanga.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

19

| HISTORY OF MALARIA IN SOUTH AFRICA: THE EARLY YEARS |

Figure 5Annual number of malaria cases and associated deaths, South Africa, 1971–2012Malaria peaked in 1985, 1993 and 2000, mostly due to antimalarial drug and/or insecticide resistance.From 2001 on, the deployment of ACTs ensured a dramatic decline in malaria case numbers, theincidence falling by 89% between 2000 and 2012.

Source: NDOH, 2013.

0

50

100

150

200

250

300

350

400

450

500

0

5000

10 000

15 000

20 000

25 000

30 000

35 000

40 000

45 000

50 000

55 000

60 000

65 000

1971 1975 1980 1985 1990 1995 2000 2005 2010 2012

Malaria cases Malaria deaths

Number of malaria cases Number of malaria deaths

South Africa formulated its Roll Back Malariastrategic plan and launched it in late 2001. Followingthe roll-out of ACTs, sustained high coverageof IRS and the adoption of regional malariacontrol strategies in South Africa, Swaziland andMozambique, the number of cases decreased to26 500 in 2001 and was consistently reduced year onyear, with fewer than 10 000 cases recorded in 2011,and 6847 cases in 2012.

The main lesson to be learned from more than70 years of malaria control efforts in South Africais that the country has been using IRS to decreasedisease burden and effective antimalarial drugsover time, adapting its policies based on timelysurveillance data used for decision-making.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

20

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

21

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

22

CHAPTER II

MALARIA CONTROL PROGRESS SINCE 2000Following a major malaria epidemic in 1999/2000, South Africa’s approach to malaria controlwas intensiÿed and necessary changes were instituted. Other key events driving this shiftincluded the signing of the RBM Abuja Declaration, which aimed to halve the malaria burdenby 2010, and the establishment of the Lubombo Spatial Development Initiative (LSDI), a public-private platform to coordinate evidence-based malaria control activities in South Africa,Mozambique and Swaziland.

The LSDI partnership facilitated the regionalimplementation of appropriate control measuresbased on evidence generated by operationalresearch and guided by rigorous monitoring andevaluation processes. The strengthened provincialmalaria control programmes, together with effectivemalaria control activities within the LSDI, resulted ina marked decline in malaria cases being reported inSouth Africa. By 2006, malaria numbers had declinedby more than 80% compared with 2000 levels, withthe most notable reductions recorded in KwaZulu-Natal. In this province, malaria cases decreased83% over the period, from 26 500 to 4400.

A review of the progress made towards the Abujatargets took place during a meeting of Africanheads of state in 2006. Sustained effective malariacontrol ensured South Africa was well on track toachieve these targets. This accomplishment wasacknowledged a year later when the SouthernAfrican Development Community (SADC) and theAfrican Union pronounced South Africa, along withSwaziland, Botswana and Namibia, as candidatesfor malaria elimination. In 2011, South Africa draftedits malaria elimination strategy (2012–2018) to guideimplementation at the provincial and district levels.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

23

| MALARIA CONTROL PROGRESS SINCE 2000 |

a.Malaria control periodIn response to the 1999/2000 malaria outbreak,existing malaria practices in South Africa werestrengthened to improve malaria control andreduce malaria-related fatalities. Provincial controlprogrammes placed speciþc focus on ensuring:

• consistent high IRS coverage rates usingeffective insecticides, including DDT, in high-risk areas;

• effective case management using RDTsand ACTs;

• routine drug and insecticide efþcacy monitoring;

• implementation of malaria information systemswith geo-localization and increased capacitydeýelopment;

• improved operational and programmaticeýaluation capabilities;

• enhanced þeld surýeillance, follow-up andinýestigation of passiýely notiþed cases andactiýe case detection (ACD) in known ‘hot spots’;

• implementation of effective information,education and communication (IEC) strategiesto increase acceptance of control measures, aswell as personal protection and health-seekingbehaviours.

The sustained deployment of new/improvedcontrol strategies in South Africa, particularly highIRS coverage rates and treatment with ACTs,resulted in a marked decline in malaria incidence.Reported conþrmed malaria case numbersdecreased from about 64 500 in 2000 to 26 500 in 2001.South Africa attempted to diagnose parasitologicallyall suspected malaria cases using microscopyfrom the mid-1990s. Since 2000, all malariacases have been diagnosed using microscopyand/or RDTs. Treatment is only prescribed if casesare conþrmed (not presumptiýely).

b.Scaling up controlBuilding on the impressive successes that thecontrol programmes demonstrated following the1999/2000 epidemic, South Africa in 2007 developeda three-year strategic malaria control policy.The goals of this new plan were to:

• prevent malaria-related mortality and toreduce morbidity, thereby contributing to theimprovement of the social and economic statusof the population;

• progressively strengthen malaria controlcapacity levels nationally and regionally, withthe speciþc aim to maintain a malaria case

fatality rate below 0.5% and reduce local casesto less than 1 case per 100 000 population at riskby 2010.

These targets were achieved after controlinterventions were enforced. IRS spray coverage inthe three South African malaria-endemic provincesconsistently exceeded 70% between 2005 and 2012(see Figure 6). Stock-outs of both RDTs and ACTswere extremely rare. Routine therapeutic efþcacymonitoring of antimalarials allowed proactivedrug policy changes in an effort to prevent thedevelopment of resistance.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

24

Figure 6IRS spray coverage in KwaZulu-Natal, Limpopo and Mpumalanga, 2005–2012The coverage of indoor residual spraying has been maintained at a high level, consistently above 80%of targeted structures in all malaria-endemic provinces since 2007/2008.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2005/2006 2006/2007 2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

KwaZulu-Natal Limpopo Mpumalanga

Malaria season

Operational coverage

Source: NDOH, 2013.

c.Strengthening the programme towardselimination

Reducing South Africa’s malaria burden was theprimary focus of the provincial control programmesuntil 2011. This course was altered in 2012, whenhealth facility case data demonstrated that manymalaria-endemic districts had already achievedthe WHO-suggested thresholds for pre-elimination(<5 cases per 1000 population at risk) and elimination(<1 case per 1000 population at risk). Guided by thedocument Malaria elimination: A ÿeld manual for low

and moderate endemic countries (published by WHOin 2007) and with the assistance of the South AfricanMedical Research Council (MRC), provincial controlprogrammes started strengthening their activities formalaria elimination.

Widespread community-based interventions are nowbeing supplemented with more targeted measuresaimed at interrupting local malaria transmission. Case

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

25


management and surveillance operations are beingintensiþed, with ACD becoming routine in all endemicprovinces. Targeted winter larviciding of potential

vector breeding sites alongside conventional IRSoperations is being piloted and could be rolled out morewidely in the near future depending on initial results.

Incidence per1000 populationat risk

0<11 to <5≥5

Reserve

Limpopo

Mpumalanga

KwaZulu-Natal


1999/2000

Limpopo

Mpumalanga

KwaZulu-Natal

2010/2011

0 70 14035 km


Note: For comparison reasons, incidence is calculated on total cases (local, unclassiÿed and imported) here.

Source: South African MRC, 2013.

Figure 7Malaria incidence in endemic provinces during the malaria transmission seasons of 1999/2000and 2010/2011The number of total malaria cases dropped signiÿcantly from 1999/2000 to 2010/2011 in all endemic areas,particularly in KwaZulu-Natal, where all district municipalities recorded less than 1 case per 1000 populationat risk in 2011.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

26

1999/2000 epidemic:about 64 500 cases

recorded

2001:ACTs phased in

2000:DDT reintroduced

1999: LSDIimplemented

pre-1999 2000–2009 2010–2012 2013–2018 Beyond 2018

1971–1995:average of5000 cases

annually

1995–1998:about85 000cases 2003: Global Fund grant for the LSDI

2003: LSDI reduces national incidenceby half compared with 2001

2013: National malariaelimination strategyimplemented

2018:MillenniumDevelopmentGoal (MDG)nationaleliminationgoal line

2006: LSDI reduces incidenceby 83% in KwaZulu-Natal(compared with 2000)

2009:Malariaprogrammereview

2011:Nationalmalariaeliminationstrategylaunched

2012/2013:<2000 local cases

2013: Vhembe and Mopanidistricts enter elimination

Figure 8South Africa’s progress on the malaria continuumGoals and interventions/strategies differ according to the control and elimination phases. Between2011 and 2012, the number of local malaria cases decreased to fewer than 2000 and the national malariaelimination strategy was implemented in 2013.


FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

27


Box 2: Interviews with key players in malaria control in thecountry

Mr Aaron MabuzaMpumalanga Malaria Control Programme Manager

To what do you attribute South Africa’s recentsuccess in reducing the country’s malaria burden?

Mr Philip KrugerLimpopo Malaria Control Programme Manager

What do you see as your biggest challenges in thefight against malaria?

South Africa and the SADC countries have all madegreat strides in the þght against malaria. Theseefforts, however, need to be sustained over manyyears in order to move towards malaria eliminationin the region. Since the 1950s, many success stories

South Africa is in the fortunate position that malariacontrol is 100% funded by government. This hasresulted in stable funding over many years, leading tothe successful implementation of the national malariacontrol policy. The major strategy, indoor residualspraying, has been sustained with a high coverageover many years. This strategy has been supportedby surveillance, malaria awareness among at-riskcommunities, prompt diagnostic testing and effectivetreatment of malaria cases, and regional collaborationwith neighbouring countries. All of these havecontributed to a gradual but sustainable reduction inthe malaria burden of the country.

have emerged from the region. These successeswere often reversed as country programmes falteredfor a variety of reasons, in most cases funding.

In the recent past, the SADC region has againprogressed as a team in the þght against malaria, withthe ultimate goal of regional elimination. The greatestchallenge remains sustaining the recent gains. Thiswould require on-going political support, funding,evidence-based policies and committed malariaprogramme managers.

As the incidence of malaria declines in South Africa,there will likely be calls for reallocating malariacontrol funds to deal with other pressing healthneeds in the country. Finding additional resourcesto implement the malaria elimination strategiesand ensuring sustained funding when malariaelimination has been achieved will be among thegreatest challenges for South Africa.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

28

Dr Devanand MoonasarNational Malaria Programme Director, South Africa

Prof. Lucille BlumbergChairperson of the South African MalariaElimination Committee

What advice and best practices can you offerother countries that are considering pursuingelimination?

The crucial practices for effective malaria controland elimination are:- ensuring sustained local þnancing, either through

public or priýate sector;- implementing practical and locally appropriate

interýentions;- ensuring adherence to the Three Ones principle:

one strategic plan, one implementation plan andone monitoring and eýaluation plan;

- securing partnerships from key stakeholders,including government, United Nations agencies,nongovernmental organizations, academia andresearch organizations, and the private sector.

Could you share your vision for the fight againstmalaria in South Africa?

For South Africa to achieve the 2018 eliminationgoal, the following actiýities will be piýotal:- strengthening parasite and vector

surýeillance;- maintaining funding and advocacy for malaria

to sustain the gains;- reducing malaria-related mortality by

introducing effective drugs, such as artesunatefor seýere malaria;

- strengthening and sustaining cross-bordercollaborations with neighbouring countries.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

29

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

30

CHAPTER III

GEARING UP A NATIONAL MALARIACONTROL PROGRAMME FOR ELIMINATIONThe decision for South Africa to embark on a malaria elimination programme was made in 2007,following the signiÿcant reduction in malaria cases and deaths. The African Union and theSouthern African Development Community also declared that countries such as South Africa,Namibia, Swaziland and Botswana should eliminate malaria. Subsequently, an intensive in-country consultative process, involving malaria experts, programme staþ and policy-makers,began to prepare for that goal.

The South African Malaria Policy was developedin 2007 and is periodically updated in keepingwith WHO recommendations. A comprehensivemalaria programme review was conducted inAugust–September 2009 to review the malariapolicies, epidemiology and programme deliverysystems and challenges, and to deþne the nextsteps to improve performance in line withelimination. This exercise was the precursorfor developing the National Malaria EliminationStrategy that was þnalized in 2011.

The following plans and guidelines have beendeveloped to assist malaria programmes implementthe policy and strategies:

• National Malaria Prevention Guidelines• Integrated Vector Control Guidelines• National Malaria Treatment Guidelines• Communication Strategy for Malaria Elimination

(2011)• National Monitoring and Evaluation Plan (2011)• Quality Control and Quality Assurance Guidelines

(2011)• National Malaria Surveillance Guideline (2012).

a.Management and planning

South Africa’s National Malaria Control Programme at a glance

• South Africa has a decentralized malaria control programme, with the National MalariaControl Programme at the National Department of Health deþning policies and guidelines,and providing technical support to provinces.

• Strategies are implemented at the provincial level, where a dedicated budget for activitiesis provided through the national treasury.

• South Africa played a key role in initiating cross-border malaria initiatives, such as the LSDIby signing a trilateral agreement with heads of states from Mozambique and Swaziland.This was one of the key contributors to signiþcantly reducing malaria morbidity and mortalityin the following years.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

31

| GEARING UP A NATIONAL MALARIA CONTROL PROGRAMME FOR ELIMINATION |

The National Malaria Control Programme (NMCP)is housed within the Malaria Directorate in theCommunicable Diseases Cluster and the PrimaryHealthCare Programmes Branch. In 2008, theCommunicable Diseases Cluster was establishedat the National Department of Health (NDOH).It includes the Malaria Directorate and theCommunicable Disease Control Directorate. TheNMCP focuses mainly on strategic issues, namelyplanning and monitoring as well as resourcemobilization, whereas the implementation of thevarious programme activities is undertaken atprovincial level.

There are three endemic provinces that haveproýincial malaria control programmes: KwaZulu-Natal, Mpumalanga and Limpopo. Large componentsof the malaria control programme at provincial leveloperate as a vertical programme (IRS, surveillanceand health promotion), whereas case managementis integrated into the primary health care system.

Malaria control within the nationaldevelopment agenda

South Africa has consistently adopted policiesand treaties/declarations aimed at reducing themalaria burden in the country. In the context ofthe health system and the national developmentagenda, the Millennium Development Goals playa key role in setting the standards of achievementfor the various targets, particularly those that arehealth-related. The NDOH, together with provinces,prioritized 18 districts in the country based on theirpoor health status, health service delivery and pooraccess to health services. Malaria is included inthe poverty reduction plan. The Malaria Directoratealigns its actiýities with the Department’s MediumTerm Strategic Framework and the 10-Point Plan,and more recently the National Service DeliveryAgreement (a performance agreement signed bythe national Minister of Health). Three malariousdistricts, Ehlanzeni, Umkhayakhude and Mopani,are among the 18 priority districts receiving specialattention and support to address lagging healthindicators. Progress on malaria control in thesedistricts is monitored and reported in the quarterlystrategic plan reports.

Figure 9Goal and objectives of South Africa’s 2012–2018 malaria elimination strategy

GOAL: TO ACHIEvE ZERO LOCAL MALARIA TRANSMISSION IN SOUTH AFRICA BY 2018

Objectives

Strengthen passive and active surveillance and monitoring and evaluation systems so that 100% ofdistricts report promptly and routinely on key malaria indicators by 2015.

Ensure that all leýels of the malaria programme haýe sufþcient capacity to coordinate and implementmalaria interventions by 2016.

Ensure 100% of the population has adequate knowledge, attitudes and practices on malaria by 2018through appropriate IEC, social mobilization and advocacy.

Prevent malaria infections effectively and eliminate all parasite reservoirs in South Africa by 2018.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

32

District epidemiological milestonestowards malaria elimination

The following milestones were set for the malaria-endemic districts (9 of 19 districts are malaria-endemic in the Limpopo, Mpumalanga and KwaZulu-Natal proýinces):

• by 2014, þýe districts (Capricorn, Sekhukhune,Waterberg, Zululand and Uthungulu) with<0.1 local case per 1000 population at risk willreach zero local cases;

• by 2016, an additional two districts (Umkhanyakudeand Ehlanzeni) will reach zero local cases;

• by 2018, the þnal two districts (vhembe andMopani) will reach zero local cases.

Key malaria control stakeholders inSouth Africa

To strengthen the implementation capacity of themalaria control programmes, several stakeholdersare inýolýed: goýernmental departments,nongovernmental organizations, research andacademic institutions, United Nations agenciesand the private sector. Stakeholders engage withthe national malaria programme through severalforums: annual planning meetings, technical

workshops and monitoring and evaluationmeetings.

South African Malaria EliminationCommittee

The malaria programme in South Africa has metsome of the incidence targets necessary to engagein the elimination stage of the disease (<1 caseper 1000 population at risk in all endemic districts)but still needs to improve case investigationand surveillance. The programme is, therefore,strengthened towards elimination under theguidance of the South African Malaria EliminationCommittee (SAMEC, formally the National MalariaAdvisory Group). Established in 2012 to guide themalaria elimination efforts of the National MalariaProgramme, SAMEC is an important committee oftechnical experts and other relevant stakeholders.It replaced the former National Malaria AdvisoryGroup established in 1994. SAMEC is divided into twosubcommittees, one focusing on case management,surveillance and health promotion, and the other onvector control.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

33

Box 3: Cross-border partnershipsSouth Africa has initiated three cross-bordercollaborations: the Lubombo Spatial DeýelopmentInitiative (LSDI), the Trans-Limpopo Malaria

Initiative (TLMI) and the MOZIZA Initiative, whichare described in the following sections.

Lubombo Spatial Development Initiative (LSDI)

LSDI started in 1999 as a large-scale project and wasinitiated in northern KwaZulu-Natal, Mpumalanga,southern Mozambique and Swaziland.

• In July 1999, the respectiýe presidents of SouthAfrica and Mozambique, T Mbeki and J Chissano,and His Majesty, King Mswati III of Swaziland,signed the General Protocol, which put in place aplatform for regional cooperation and delivery.

• In October 1999, the Lubombo Malaria Protocoland tri-national malaria programme was launched.

• The LSDI is a partnership between the malariacontrol programmes of South Africa, Swazilandand Mozambique, and the South African MRC.

• The LSDI aims to accelerate development,particularly in tourism, within an area ofapproximately 100 000 square kilometres.

LSDI objectives

• Reduce malaria incidence in the border areas ofSouth Africa and Swaziland from 250 per 1000 toless than 20 per 1000.

• Decrease malaria infections from 625 per 1000 tofewer than 200 per 1000 within three years afterthe start of IRS activities in Maputo Province.

• Provide updated tourist information and bookletscontaining deþnitiýe malaria risk maps andprophylaxis guidelines.

• Develop a regional malaria control programme.

• Develop a regional geographic information system(GIS)-based malaria information system.

• Implement parasitologically conþrmed diagnosisof malaria and effective treatment.

LSDI progress

• Almost US$ 80 million has been raised forimplementing the control programme in the LSDI,most notably in Mozambique.

• Malaria incidence has declined in South Africa(KwaZulu-Natal and Mpumalanga provinces) andin Swaziland (Lubombo) by 99% compared withthe 2000 baseline.


Honourable Valli Moosa, South Africa’s formerMinister for Environmental Aþairs, at the launch of

the trilateral LSDI in 1999.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

34

• In KwaZulu-Natal and Mpumalanga, malariaincidence respectively decreased by 99% (fromabout 42 400 to 550 cases) and 72% (from about12 000 to 3350 cases) between 1999/2000 and2010/2011.

• The prevalence of the disease had decreased by92% in southern Mozambique up to 2009.

• This model has proven to be successful in malariacontrol and been the model for other initiatives,such as the Trans-Zambezi Malaria Initiative(TZMI) involving Angola, Botswana, Namibia,Zambia and Zimbabwe, and the Trans-KuneneMalaria Initiative (TKMI) with Angola and Namibia.

• Unfortunately, funding for the LSDI dried up,although many malaria control stakeholders inSouth Africa remain hopeful it can be revived.

MOZAMBIQUELIMPOPO

MPUMALANGA

KWAZULU-NATAL

GAZA

MAPUTO

SWAZILAND

Mopani

Ehlanzeni

Vhembe

Zululand

Uthungulu

Umkhanyakude

Zone 1

Zone 3

Zone 2Manhica

Zone 2A

Zone 1AMatola City

Zone 7

Zone 4

Zone 6

Zone 5

Lubombo Indian Ocean

Incidence per1000 population at risk

Prevalence

≤ 5%0–12–56–2526–100101–144Reserve

> 5% to 20%>20% to 40%>40% to 60%>60% to 80%>80%

Baseline survey years for Mozambique vary as follows:Gaza: 2004–2007; Maputo: 1999–2003

BASELINE (1999/2000) 2010/20110 110 22055 km

SOUTH AFRICA

MOZAMBIQUELIMPOPO

MPUMALANGA

KWAZULU-NATAL

GAZA

MAPUTO

SWAZILAND

Mopani

Ehlanzeni

Vhembe

Zululand

Uthungulu

Umkhanyakude

Zone 1

Zone 3

Zone 2Manhica

Zone 2A

Zone 1AMatola City

Zone 7

Zone 4

Zone 6

Zone 5

Lubombo Indian Ocean

SOUTH AFRICA

Figure 10LSDI intervention districts and outcomesThe LSDI produced big strides in reducing malaria cases in Swaziland and Mozambique. It alsohad a remarkable impact in KwaZulu-Natal, where cases dropped by 99% between 1999/2000 and2010/2011 to less than 1 case per 1000 population at risk in all districts and municipalities from thisprovince.

Map production: Malaria Research Unit, South African MRC (Durban).

Source: LSDI, Annual Report, 2012.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

35


Trans-Limpopo Malaria Initiative (TLMI)

The TLMI was started in 2001 as part of theborder Trans-Limpopo Spatial DevelopmentInitiative (TLSDI) and targeted MatabelelandSouth Province (Beitbridge, Mangwe, Bulilimaand Gwanda districts) in Zimbabwe, and Limpopo(Vhembe district) in South Africa. Initiallycreated as an information-sharing platform, thiscollaboration aims to reduce malaria transmissionon the borders along the Limpopo River.

Zimbabwe and South Africa have invested theirown resources in malaria control within the TLMIarea. However, a lack of human and financialresources has hampered efforts to fully implementthe initiative, while unforeseen malaria epidemicsand highly mobile populations across the bordershave also provided challenges. The initiativegained momentum on the back of LSDI successesand has strong political backing from former andcurrent ministers of health.

Key facts

• Three districts/municipalities inýolýed: Beitbridgein Zimbabwe, and Musina and Mutale inSouth Africa.

• Population at risk in the three districts is276 000.

• Anopheles arabiensis is the major vector withP. falciparum the major parasite species.

• In 2009, malaria incidence in the Trans-Limpoporegion ranged from 2.01–5/1000 population at riskin Musina municipality in the Limpopo province ofSouth Africa to 10.01–45/1000 population at risk inthe Beitbridge district of Zimbabwe.

Rationale for the TLMI

• Increased cross-border movement of malaria-affected populations.

• Inadequate harmonization (disease managementand treatment guidelines) and coordination(e.g. cross-border referrals and continuity ofcare).

• Inadequate disease surveillance and epidemicpreparedness plans can lead to public healthrisks and events.

• On top of existing language barriers, there isinadequate information and education of mobilepopulations/locals affected by malaria.

• Limited communication between malariacontrol programmes/cross-border districts.

TLMI objectives

• Harmonize malaria control strategies (namely onvector control and case management) on eitherside of the border to make sure WHO-approvedevidence-based interventions are optimallyimplemented.

• Increase the scale and impact of vector controlefforts so that 95% of people in the Trans-Limpopoareas are protected by IRS by 2015.

• Develop and maintain a surveillance system forboth malaria parasitology and entomology.

• By 2014, ensure microscopy or RDT testingof all suspected malaria cases presenting athealth facilities, and appropriate treatment ofall conþrmed cases within 24 hours of onset ofsymptoms.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

36

TLMI progress

• Policies were harmonized for antimalarial drugs(artemisinin-based combination therapies) andinsecticides (use of DDT and pyrethroids) forvector control.

• IRS coverage is approximately 90% across theTrans-Limpopo area.

• Malaria incidence was reduced markedly acrossthe Trans-Limpopo area between 2009 and 2012(see Figure 11).

• All malaria cases are treated based onparasitologically conþrmed diagnosis of malaria.

Figure 11Incidence of malaria in TLMI intervention districts, 2009–2012In the whole targeted Matabeleland South province of Zimbabwe, malaria incidence was reducedsignificantly from 2009 to 2012, to between 0 and 5–6 cases/1000 population at risk. In Musina andMutale (South Africa), it dropped respectively 57% and 55%, to 2.2–4.2 cases/1000 population at risk.


Namibia

South Africa

Lesotho

Swaziland

Mozambique

Zimbabwe

Botswana

2009 20120 80 160 km40

Game reserveAll-case incidence per 1000 population at risk0–0.5 >0.5 to 1 >1 to 2 >2 to 5 >5 to 10 >10 to 45

BOTSWANA

SOUTH AFRICA

MOZ

AMBI

QUE

ZIMBABWE

Lephalale

Musina

Thabazimbi

Mutale

Thulamela

Greater Giyani

Ba-Phalaborwa



Insiza

Gwanda

Beitbridge

Matobo

Bulilima (North)

Mangwe (South)

Umzingwane

Matebeleland South

Limpopo

BOTSWANA

SOUTH AFRICA

MOZ

AMBI

QUE

ZIMBABWE

Lephalale

Musina

Thabazimbi

Mutale

Thulamela

Greater Giyani

Ba-Phalaborwa

Insiza

Gwanda

Beitbridge

Matobo

Bulilima (North)

Mangwe (South)

Umzingwane

Matebeleland South

Limpopo

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

37


MOZIZA Initiative

The MOZIZA Initiative was established in 2010 toinclude parts of northern Mozambique and somedistricts from southern Zimbabwe that were partof the TLMI, as well as some additional districts.It is a malaria-control collaboration betweenMozambique, Zimbabwe and South Africa that aimsto reduce malaria transmission in the targetedregion (2.3 million people at risk in 9 districts).The incidence of malaria in Vhembe district (SouthAfrica) was approximately 1.69/1000 population atrisk compared with 335– 395/1000 population atrisk in parts of northern Mozambique and south-eastern Zimbabwe (see Figure 12).

Rationale for MOZIZA

• Porous borders pose a threat to containing andreducing transmission.

• Uncoordinated malaria control interventionsincrease the risk of resistance and wastage ofþnancial resources.

• Limited partnership and knowledge-sharingbetween countries.

• Poor regional service delivery and resourceallocation.

MOZIZA objectives

• Reduce the number of malaria cases by at least50% in MOZIZA-targeted districts within fiveyears (by 2016) by:- harmonizing cross-border malaria service

delivery among border districts, provinces andnations, through effective joint managementand coordination;

- strengthening regional malaria surveillanceand information systems to respond to malariacases in an appropriate and timely manner;

- improving knowledge and practices ofmigrant populations, travellers and bordercommunities to prevent and control malaria.

MOZIZA progress

Lack of funding is a major impediment for theMOZIZA initiatiýe; attempts to secure þnancing fromthe Global Fund to Fight AIDS, Tuberculosis andMalaria have been unsuccessful.

Despite this funding shortfall, it is worth noting thatin South Africa’s targeted area of MOZIZA (vhembedistrict, composed of four local municipalities,including Mutale and Musina, which beneþt fromthe TLMI), malaria incidence fell by 72%, from1.69/1000 population at risk to 0.47/1000 between2009 and 2013.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

38

Figure 12Incidence of malaria in MOZIZA intervention areas, 2009In the provinces targeted by the MOZIZA Initiative, malaria incidence ranged from 1.69/1000 populationat risk in Vhembe district (Limpopo, South Africa) to 335–395/1000 in Massangena (Gaza, Mozambique)and Chipinge (Manicaland province, Zimbabwe) in 2009.


KrugerNational

Park

Namibia

South Africa

Lesotho

Swaziland

Mozambique

Zimbabwe

Botswana

0 60 120 km30

Game reserve

All-case incidence per 1000 population at risk

1-5

25-50

120-135

205-235

335-395

BOTSWANA

MOZAMBIQUE

ZIMBABWE

SOUTH AFRICA

Vhembe

Chiredzi

Machaze

Mwenezi

Chicualacuala

BeitbridgeMassangena

Chipinge

Mossurize

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

39


b.Securing appropriate funding

Funding for malaria elimination in South Africa at a glance

• Funding for malaria control programmes in South Africa has been solely throughgovernmental sources, with limited support from partners for workshops, reviews andtechnical assistance.

• The national budget for malaria control increased signiþcantly between 2007 and 2008,reaching an average of US$ 25 million annually between 2009 and 2012.

• A malaria elimination plan was developed focusing on the key intervention areas, but thereis a gap to fully fund elimination strategies around vector control, surveillance and healthpromotion.

• Innoýatiýe funding mechanisms are required to close the þnancial gap for malariaelimination, either through a governmental intersectoral approach for interventions suchas surveillance, case management and health promotion, or for securing local funding fromprivate sector partners and funding agencies.

South Africa has been able to adopt andimplement policies that are evidence based andpractical. The malaria control programme hasalso been able to support and sustain malariacontrol interventions for more than 70 years fromits own resources, and today, like other countriestargeting malaria elimination, South Africacannot rely on external funding to align with the2012–2018 elimination strategy.

In the past, the malaria programme in South Africaalso showed its capacity to mobilize financialresources at short notice, as evidenced by the1999/2000 malaria season when US$ 5.7 millionwas mobilized to support malaria outbreak efforts

in Limpopo, Mpumalanga and KwaZulu-Natalprovinces.

As shown in Figure 13, domestic funding rosesignificantly from 2007 to 2008, stabilizing at anaverage of US$ 25 million annually between 2009and 2012. A gap analysis in 2011 highlighted thatthe national budget for malaria control needsto be increased in order to achieve the goal ofelimination. Reaching zero local malaria caseswill require increased financial resources, andsignificant human and financial resources willneed to be sustained after elimination is achievedto prevent the reintroduction of malaria toSouth Africa.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

40

Figure 13Domestic and external funding for malaria control and elimination, South Africa, 2007–2012Domestic funding for malaria control increased by about 40% between 2007 and 2008 and has hoveredat about US$ 25 million since then, with a slight drop in 2012.

Government Others

0

5

10

15

20

25

30

2007 2008 2009 2010 2011 2012

Year

US$ (in millions)

Note: Other bilaterals providing funding are WHO and nongovernmental organizations.

Source: World Malaria Report 2012 and NDOH, 2013.

The malaria control programme in South Africahas drafted and costed its malaria elimination plan.The total cost for the programme is estimated

at US$ 305 million for the 2012–2018 period, the threemalaria-endemic regions representing 94% of thenational malaria budget.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

41


Figure 14Malaria elimination costs by province, South Africa, 2012–2018The total costs of malaria elimination for 2012–2018 were budgeted at US$ 305 million. Mpumalanga andKwaZulu-Natal each account for approximately a quarter of this budget, Limpopo 43%, and the rest isscattered across other South African provinces.

All other provinces

KwaZulu-Natal

Limpopo

Mpumalanga

North West

Gauteng

25%

2% 2% 2%

26%

43%

Source: NDOH, 2013.

The funding gap to take the programme to eliminationhas been estimated at US$ 90 million. Whenstratifying malaria elimination costs by intervention

areas it is evident that the highest cost driver willbe for surveillance, followed by vector control asillustrated in Figure 15.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

42

Figure 15Malaria elimination funding gaps by intervention, South Africa, 2012–2018Reflecting the transition to a pre-elimination approach, malaria expenditures will primarilyfocus on surveillance, and the funding gap is highest for this specific intervention. Of the totalUS$ 90 million shortfall until 2018, vector control and health promotion activities account for 22% and14% respectively.

Vector control

Surveillance

Health promotion

Case management

Programme management

14%

3% 3%

58%

22%

Source: NDOH, 2013.

This funding gap will need to be closed to ensuremalaria elimination becomes a reality. Giventhe competing funding requirements for otherpriority programmes in South Africa, such asHIV/AIDS, tuberculosis, primary health care (PHC)re-engineering and the National Health InsuranceSystem (NHIS), it will be important to þnd

innovative funding solutions for the malariaelimination programme. Donor funding will notbe the solution as this could prove unreliable.Integrating surveillance within PHC would offerthe beneþts of streamlining malaria eliminationactivities within the NDOH and reducing theperceived cost of elimination.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

43


c.Intervention strategies

Intervention strategies at a glance

• Elimination interventions include integrated vector management (IRS and larviciding), casemanagement, surveillance and health promotion.

• IRS coverage of targeted structures was 88% on average in malaria-endemic provincesbetween 2000 and 2012, with about 1.8 million structures sprayed in 2012/2013.

• From 2000, all suspected malaria cases have been diagnosed using microscopy and/or RDTs. In2011, 61% and 39% of malaria cases were respectiýely conþrmed by microscopy and RDT.

• All positive cases are treated within 24 hours, and treatment is only prescribed once casesare conþrmed (not presumptiýely).

• More than 7700 spray operators were trained between 2005 and 2012; an aýerage of500 doctors and nurses are trained each year in managing seýere malaria; and regulartraining sessions in malaria case management are organized for health-care workers.

• Health promotion plays an important role during the annual SADC malaria events, as wellas during the spraying and active surveillance sessions conducted in various communities.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

44

In 2000, the South African Malaria ControlProgramme reintroduced DDT for malaria vectorcontrol (after curbing its use in 1996) due to theresistance of existing insecticides (pyrethroids).The use of DDT has become more judicious in recentyears, with targeted spraying only in high-risk areasof the malaria-endemic provinces. In endemic areas,IRS information has been computerized, down to thedistrict level.

Integrated vector management (IVM)

Vector control has played a major role in reducingAnopheles funestus populations. Apart from IRS,which is the mainstay of South Africa’s ýectorcontrol programme, other IVM interventions includelarviciding, insecticide resistance managementsuch as rotating different classes of insecticides,annual training of spray operators, collaborationwith other departments such as the Departmentof Environmental Affairs and the Department ofAgriculture, Forestry and Fisheries (especially inthe implementation of the Stockholm Convention,aiming at eliminating or restricting the productionand use of persistent organic pollutants), andadvocacy for IVM interventions by the healthpromotion units of the Department of Health.

Larviciding activities have been carried out in thethree endemic provinces as the vector controlteams come across breeding sites during activesurveillance. Mpumalanga recently introducedsystematic winter larviciding, which was conductedon 547 breeding sites during the 2011/2012 malaria

season, with a corresponding 39% reduction oflocal malaria cases in the Nkomazi municipality.During the year 2012/2013 the province managedto identify and treat approximately 3700 permanentand 2600 temporary breeding sites. To achievethe elimination goal of effectively preventing localmalaria infection, one of the indicators in themalaria monitoring and evaluation plan requiresthat permanent and potential breeding sites beidentiþed and treated. Other types of larýal sourcemanagement such as habitat manipulation areencouraged through health promotion messages tomembers of the community in endemic areas.

IRS coverage

South Africa has maintained a high IRS operationalcoverage over the past 13 years, with an averageof 88% between 2000 and 2012, well above theWHO recommended minimum coverage of 80%.The IRS coverage represents the number of targetedstructures that have been sprayed in the endemicprovinces. There is also limited spraying takingplace in North West province, which previouslyreported local malaria cases. Every year an averageof 335 spray operators are engaged in IRS in theendemic provinces. These include permanent andtemporary spray operators who are trained in thesafe use of insecticides at the beginning of eachspray season. The IRS campaigns take place inall the localities earmarked for spraying, betweenSeptember and March each year.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

45


Figure 16Number of structures sprayed with IRS and operational coverage in the three malaria-endemicprovinces, South Africa, 2000–2012Since 2005, more than 1.5 million structures have been treated with IRS each year, and the operationalcoverage has consistently been above 80% during the past 13 years.

Number of structures targeted/sprayed

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0

250 000

500 000

750 000

1 000 000

1 250 000

1 500 000

1 750 000

2 000 000

2 250 000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Operational coverage

Targeted Sprayed Operational coverage

Source: NDOH, 2013.

IRS has been the cornerstone of malaria controlfor more than 70 years in South Africa. Insecticideresistance in vector populations in South Africarequires tailored strategies by region/province tomanage resistance and maintain vector controlefþcacy.

Malaria ýector control in South Africa’s threemalaria-affected provinces is based on an IRSapproach in which deltamethrin is used for cement-brick structures, while DDT is used for traditionalmud-walled structures. Carbamates are also used intwo instances: to contain pyrethroid resistance andas a substitute for DDT in painted houses of areasof KwaZulu-Natal. This mosaic approach, whereby

one compound is used in one geographic area and adifferent one in neighbouring areas (the two being indifferent insecticide classes) is part of the insecticideresistance management strategies initiated byWHO in the Global Plan for Insecticide ResistanceManagement (GPIRM) in 2012.

IVM is also part of the cross-border malaria controlinitiatives with neighbouring countries, which iscritical to South Africa’s malaria elimination agenda.

Programmatic organization

Due to the seasonal nature of malaria inSouth Africa, IRS campaigns take place before the

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

46

main transmission season, commonly before theend of December. The majority of spray operatorsare employed as temporary workers; training, on thecorrect application of insecticides, safe handlingand waste disposal, takes place annually. Morethan 7700 spray operators were trained between2005 and 2012.

Record-keeping systems are also in place for IRSactiýities. These consist of ‘hutcards’ completedat each sprayed dwelling that include pertinentinformation such as the date of spraying, insecticideused and spray operator’s details. This card remainswith the householder for future monitoring andrecord purposes. The daily performance of sprayoperators is also recorded, with spray data enteredinto electronic information systems.

Opportunities to improve IRS through betterstratiþcation of spraying actiýities are beingexplored. These include using GISs to monitor andrecord spray performance at household level, aswell as linking IRS information to malaria casenotiþcations within communities. They will helpovercome current challenges, such as the growthof communities in endemic areas that exceeds the

capacity of the malaria spray teams, and the difþcultyin achieving high IRS coverage in sophisticateddwellings or among households that do not acceptDDT because of stains left on walls.

Entomological surveillance

Analysis and decision-making for IRS, particularlyfor insecticide resistance management, is notpossible without skilled entomological support andthere is a shortage of trained entomologists in theAfrican continent, including in South Africa. Thereis a need for the national and provincial malariacontrol programmes to develop capacity withinthis þeld so that appropriate guidance and supportcan be provided to malaria vector control activities.The national and provincial programmes will haveto consider how to best þll this competency andposition gap, particularly in the light of malariaelimination. The National Department of Healthneeds to create career paths to make the studyof entomology a more attractive proposition.Meanwhile, the malaria programme will need towork with its partners from research institutes suchas the National Institute for Communicable Diseasesto remedy the lack of trained entomology staff.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

47


Diagnostic testing

In response to delayed, standardized malariamicroscopy, the South African Department of Healthin 1996 became the þrst African health ministry toimplement a policy of parasitological conþrmationof malaria diagnosis, using RDTs targeting theP. falciparum histidine-rich protein 2 (HRP2) atprimary health clinics in malaria risk areas.

The South African malaria diagnosis guidelinesexplicitly require that a suspected malaria infection

be conþrmed or excluded with a blood test. From2000 on, all suspected malaria cases have beendiagnosed using microscopy and/or RDTs, with allpositiýe cases treated within 24 hours; treatmentis only prescribed once cases are conþrmed, notpresumptively. Out of the 9900 reported cases ofmalaria in 2011, 6000 and 3900 were conþrmed bymicroscopy and RDT respectively, and all weretreated according to guidelines. The distributionof conþrmed cases across diagnostic tools isillustrated in Figure 17.

Figure 17Diagnostic tools used for confirming malaria cases, South Africa, 2011Malaria cases in South Africa are mostly confirmed using microscopy.

Microscopy

RDT

39%

61%

Source: World Malaria Report 2012.

In low-resource settings, RDTs are a suitablealternative to microscopy as they are relativelysimple to perform, allowing for point-of-carediagnosis and immediate malaria treatment. In 2012,about 400 000 RDTs were delivered countrywidebased on the 380 000 suspected malaria cases ofthe preceding year. RDT suppliers vary from one

year to the next, so data on quantities supplied arenot readily available, and RDT use is not routinelycollected in South Africa, hence a trend on themalaria conþrmation rate oýer the years cannot beobtained. The programme will address this issuein the coming years as it charts its way towardselimination.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

48

Within the hospital service, microscopicexamination is the operational gold standard fordiagnosing malaria. It is carried out by the NationalHealth Laboratory Service (NHLS), comprised of260 laboratories serving more than 80% of thepopulation and private laboratories serving theprivate sector, as well as provincial malariacontrol programmes. Since 2009, microscopy isconducted according to prescribed standardsby trained medical technologists in all NHLS andprivate laboratories.

In the past decade, there has also been a drivetowards accreditation of medical laboratories,conþrming that laboratories are using appropriateinternal and external quality controls. Approximately30% of all laboratories were accredited at the end of2012. This þgure is skewed in faýour of laboratoriesin academic complexes. In line with the NHLS, alllaboratories will need to be accredited by 2015.

RDTs have proved extremely cost-effective andefþcient during the malaria control phase insupporting case management but, because oflimited sensitivity at low levels of parasitaemiaand the importance of detecting such infectionsto halt the transmission cycle, their usefulness asthe country moves towards malaria elimination islimited. This highlights the need to develop anddeploy more sensitive diagnostic techniques, suchas polymerase chain reaction (PCR), especially foractive case detection. South Africa will evaluatea malaria diagnostic method, loop-attenuated

isothermal ampliþcation (LAMP), which has fewertechnical requirements than PCR, and is possiblymore appropriate for þeld use. An indirect approachto detecting malaria exposure is serologicaltesting to detect parasite-speciþc antibodies.This technique has been used successfully inSomalia and Tanzania to determine malariaexposure and changes in transmission intensity atthe population level. If South Africa is to meet itselimination target, malaria conþrmation using oneof these more sensitive methods must becomestandard procedure at appropriate laboratories.This will allow for more precise calculations ofmalaria case numbers while assisting with controlactivity planning.

Treatment

In 2001, South Africa, notably KwaZulu-Natal,was instrumental in introducing ACTs for casemanagement subsequent to parasitologicallyconþrmed diagnosis. According to the nationalmalaria treatment guidelines, all conþrmed malariacases must now be notiþed within 24 hours andtreated promptly.

South Africa was one of the þrst countries in Africato introduce ACTs in response to rising resistanceto SP. By 2006, all the endemic provinces wereusing ACTs. The number of ACT treatment coursessupplied to both the public and private sectors since2008 is shown in the þgure below.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

49


Figure 18Number of ACT treatment courses delivered to the public and private sectors, South Africa,2008–2012From 2008 to 2012, an average of 27 000 ACT treatment courses were distributed yearly to the publicand private sectors in South Africa.

0

5000

10 000

15 000

20 000

25 000

30 000

35 000

40 000

2008 2009 2010 2011 2012

Year

Source: NDOH, 2013.

The national malaria treatment policy in South Africaadvocates for treating all parasitologicallyconþrmed malaria cases. In 2012, there were6847 conþrmed and treated malaria cases, while27 000 ACT treatment courses were distributed.It will be important to gauge the total utilization ofACTs against those distributed as this will give aclear indication of inappropriate usage of the drug(under- or over-utilization). Currently the malariacontrol programme in South Africa does not routinelycollect RDT and ACT utilization data as this function

lies with pharmaceutical units and obtaining thedata is difþcult. Anecdotally, malaria managersare conþdent there are seldom stock-outs of RDTsand ACTs, and that all conþrmed malaria cases aretreated with ACTs for uncomplicated malaria andwith quinine for complicated malaria, especially inthe endemic provinces. However for South Africa totrack its delivery and usage of diagnostic tests andACTs, it needs to ensure that this data is routinelycollected. The programme will address this issue asit charts its way towards elimination.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

50

District health systems (DHS) based on primaryhealth care (PHC) have been adopted as the health-care strategy for South Africa since 1994. Thesubsequent integration of passive diagnosis andtreatment of malaria into PHC within the DHS, andthe introduction of RDTs at the PHC level startingin 1996 revolutionized malaria case detection andtreatment at health-care facilities across malaria-endemic areas in the country.

First-line treatment of uncomplicated malaria withACTs (artemether-lumefantrine [AL]) was adoptedin 2001 in KwaZulu-Natal, in 2004 in Limpopo, andin 2006 in Mpumalanga. Severe malaria cases aretreated with initial parenteral quinine followed bydoxycycline, clindamycin or AL. The non-endemicprovinces have also adopted the use of ACTs fortreating uncomplicated Plasmodium falciparum asrecommended in South Africa’s malaria treatmentguidelines. Parenteral artesunate for the treatmentof severe malaria, which has been demonstrated tobe more efþcacious than quinine and recommendedby WHO since 2011, has been successfullyimplemented as part of a special access programme,with the hope that the drug will be registered andmore widely available in the near future.

Malaria diagnosis by parasitological tests andtreatment with efþcacious antimalarial medicinesare provided free of charge at all levels of formalhealth-care facilities in the endemic areas inSouth Africa. Mortality audits are conducted on themalaria-related deaths and health system problemsare documented. A goal of near-zero malaria deathsby 2015 has been set.

A Roll Back Malaria baseline survey conductedunder the aegis of the NDOH in 2005 revealed that100% of patients diagnosed with malaria weretreated appropriately within 24 hours, and thistrend has been maintained (information providedby provincial malaria control managers). InSouth Africa, a key challenge is collectinginformation on RDTs and ACTs from the provincesand districts, as this information is integratedwithin the pharmaceutical units and obtaining it isdifþcult.

For South Africa to track delivery and use of ACTs,it needs to ensure that data are routinely collected.The programme will address this issue as it chartsits way towards elimination.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

51

1 Freese JA et al. In vitro conÿrmation of chloroquine-resistantPlasmodium falciparum malaria in KwaZulu. South African MedicalJournal, 1988, 74(11): 576–578.

2 Deacon HE, Freese JA, Sharp BL. Drug-resistant Plasmodiumfalciparum malaria in the eastern Transvaal. South AfricanMedical Journal, 1994, 84(7): 394–395 and Kruger P, Durrheim DN,Hansford CF. Increasing chloroquine resistance - the MpumalangaLowveld story, 1990–1995. South African Medical Journal, 1996,86(3): 280–281.

3 Bredenkamp BL et al. Failure of sulfadoxine-pyrimethamine intreating Plasmodium falciparum malaria in KwaZulu-Natal. SouthAfrican Medical Journal, 2001, 91(11): 970–972.

4 Guidelines for the treatment of malaria in South Africa. SouthAfrican National Department of Health, 2010.


Drug resistance

South Africa has been at the forefront of revisingpolicies to ensure effective drugs are used in itsmalaria control programme. The selection of drugsis based on sound scientiþc eýidence. Historically,South Africa used chloroquine in its malariaprogramme to treat uncomplicated malaria, andquinine for complicated malaria. Drug resistance tochloroquine was þrst reported in KwaZulu-Natal in1987, where an in vitro drug resistance study found88% parasite resistance to the drug.1 Drug policysubsequently changed from chloroquine to SP in1988 in KwaZulu-Natal. Chloroquine resistancewas also reported in Mpumalanga and Limpopoprovinces, necessitating a policy change to SP inthese provinces in 1997.2

SP resistance started rising in the mid-1990s andreached approximately 80% in 2000, requiring achange in drug policy to AL in 2001 in KwaZulu-Natal.3 Subsequently, in 2004, Limpopo also replacedSP with AL, while Mpumalanga used SP-artesunatein the public sector from 2001 to the end of 2005 andhas implemented AL since January 2006.4

The South African MRC carries out drug resistancetesting. Artemether-lumefantrine remains the mostefþcacious þrst-line drug for treating uncomplicatedmalaria cases in South Africa and no resistance hasbeen documented to date.

Surveillance

South Africa has built a surveillance programme,which is in place in all three endemic provinces andis described in detail in Box 5.

The reorientation of the malaria programmetowards elimination has led to strengthenedsurveillance systems to improve weekly and monthlyreporting, but much still needs to be done to reachSouth Africa’s surýeillance objectiýes, namelynotiþcation of malaria cases within 24 hours ofdiagnosis and inýestigation of conþrmed malariacases within seýen days of notiþcation.

The proportion of cases detected through activesurveillance is low, even in the provinces that havea robust programme. For example, in Mpumalanga(further presented in Box 5) only 5% of malariacases were detected through active case detection(ACD) in 2011. That year, only 25 malaria caseswere detected in KwaZulu-Natal following ACDundertaken in about 494 000 households. In movingtowards elimination, a new case investigationform has been developed and is being piloted inthe endemic provinces and in two non-endemicproýinces. The malaria surýeillance ofþces andcase investigators have been supplied withGIS equipment to assist in mapping localitiesvisited during parasitological and entomologicalsurveillance.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

52

Box 4: Malaria health promotion from control to eliminationHealth education and promotion, in addressingthe key risk factors, have played an importantrole in reducing malaria morbidity and mortality.Community members are generally informed ofa speciþc interýention, especially after a majoroutbreak such as in 1999/2000 when more than64 500 cases were recorded. Recently, with thereduced number of malaria cases, health-careworkers and communities may perceive malaria as

less of a threat, particularly in the context of thehigh disease burdens of tuberculosis and HIV/AIDSin South Africa.

The National Malaria Control Programme hasidentiþed that robust adýocacy and a healthpromotion and communication strategy are requiredto move from control to elimination.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

53


The aim of the strategy is to strengthen communityaction, which requires the following:

- strong advocacy targeting political, economic,social, cultural and enýironmental factors;

- creating an enabling environment thatsupports health system capacity developmentand access to information, with sustainableintegrated systems in place to support theinitiatiýe;

- establishing partnerships that will ensurecoordinated action by governments, health,social and economic sectors, nongovernmentaland voluntary organizations, local authorities,industry and the media.

This involves advocating for community supportin endemic and non-endemic districts to supportthe elimination strategy and develop materialsabout the disease and the related interýentions:signs and symptoms, prophylaxis, vector control,environmental management and personalprotection.

The approach in South Africa will be for everyperson to ask, ‘What role do I play in order for us toreach malaria elimination?’ For this to occur thereis a need to conýey speciþc messages to differentgroups. Action is required through educational,professional, commercial and voluntary bodies,and within the institutions themselves.

Communities in South Africa are diverse, withvarious cultural beliefs. Target messages needto be appropriate and aimed at communities asindividuals and families in the social constructof home, work, school and recreational activity.Audiences will include politicians in all spheresof government, policy-makers, communityleaders, traditional healers, nongovernmentalorganizations, interdepartmental associations, theprivate sector and other partners.

Delivery channels

In South Africa, knowledge, attitudes and practices(KAP) surveys conducted in 2005 and 2006 indicatedthat the community was aware of malaria,with the radio one of the important channels ofcommunication. A KAP survey in 2008 determinedthat communication channels for informationabout malaria were, in order of preference: healthfacilities where talks and one-on-one sessions wereconducted; the radio; and pamphlets and posters.

Delivery channels will be aimed at the targetaudience; for example, the approach forcommunicating with travellers could be to havea web site providing an information technologyapplication, or displaying IEC material at ports ofentry such as border posts and airports, emphasizingwhere prophylaxis is available.

IEC/behaviour change communication

Behaviour change communication is a key aspectin moving towards malaria control, especially innon-endemic areas of the country – Gauteng forexample – which are targeted by migrants comingfrom endemic areas. In the past two years,workshops have been held to improve malariaawareness among health-care workers andcommunities at highest risk of malaria, such as thefrequent travellers to neighbouring Mozambiquewhere the majority of imported cases originate.In addition, between 2010 and 2013, two millionpamphlets were produced by the National MalariaControl Programme and distributed to all provinces.Posters about managing severe malaria have alsobeen developed and printed, aimed at reducing thenumber of malaria-related deaths.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

54

d.Impact and cases averted

Impact and cases averted at a glance

• South Africa has rolled out several interventions that have reduced malaria morbidity andmortality by 89% and 85% respectively between 2000 and 2012, from 64 500 to 6847 malariacases, and from 460 to 70 deaths.

• Between 2011 and 2012, local and imported cases decreased by 18% and 24% respectively.

• The effectiveness of malaria control in KwaZulu-Natal over the decade from mid-2002 wasestimated at 97% when compared with the 2000 experience, malaria control measuresaverting on average 165 000 cases per annum in the three endemic provinces.

• Malaria control has had a major impact on disease burden, as well as on the economic andsocial development in malaria-endemic provinces.

Malaria control has been conducted for morethan 70 years in South Africa. Accurate recordsof malaria incidence prior to the introduction ofcontrol measures do not exist, and therefore, a pre-intervention estimate of the malaria disease burdenis not plausible. Historical records do, however,indicate malaria endemicity was a major obstacleto economic growth, particularly hamperingagricultural and industrial activities.

The cornerstone of malaria prevention inSouth Africa, namely IRS, is an intervention whoseimpact has neýer been reliably quantiþed, and itscumulative effect over many decades is hard toassess precisely. Malaria incidence in recent yearshas been low in comparison with early records duringthe control era, likely the result of a combination ofbroad coverage IRS vector control, effective casemanagement and regional malaria control. Between2000 and 2012, the number of malaria cases andrelated deaths fell by 89% and 85% respectively,from 64 500 to 6847 cases, and from 460 to70 deaths, largely thanks to effective preventive

and therapeutic interventions. Urbanization,economic and infrastructural development, togetherwith housing improvements, have also contributedto the decline in malaria cases and deaths.

The malaria epidemic of 1999/2000 in KwaZulu-Natal provides an indication of what might happenin the absence of effective control measures.The epidemic occurred before regional malariacontrol interventions were put in place in southernMozambique. Furthermore, resistance to theinsecticide and antimalarial drug developed due toweaker control efforts in the province.

To provide a rough calculation of the combinedaverage effectiveness of IRS, case managementand regional malaria control in South Africa (thatis, when an insecticide and an antimalarial drugto which vector and parasite are susceptible areused, and with regional malaria control occurringin Mozambique), the notified cases recorded aslocally acquired from the year 2000 were used asa lower estimate of KwaZulu-Natal case numbers

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

55


in the absence of control measures. Assumingthe preventive effectiveness of this combinedpackage of IRS, case management and regionalmalaria control, averaged over 10 years, to be ofsimilar magnitude in all three malaria-endemic

provinces, the minimum number of cases thatcould be expected in each province without thesemeasures were calculated using the followingmethod:

Calculation method for averted malaria cases

Effectiveness of the malaria control package=1 – (N1/N0),

whereN1=number of malaria cases reported as locally acquired remaining in the presence of malariacontrol; and N0=number of malaria cases reported as locally acquired in the absence of malariacontrol.

Therefore, with combined interventions effective from mid-2002 (when the Lubombo SpatialDevelopment Initiative was still in progress with the introduction of IRS and effective casemanagement in southern Mozambique; and when neither artemisinin-containing combinationmalaria treatment with known local parasite resistance, nor insecticide with recorded resistance inthe Anopheline populations responsible for local transmission were in place)

Average Effectiveness2003–2012=1-(average NKZN2003, NKZN2004 … NKZN2012)/(NKZN 2000)

where NKZN2000 = number of cases reported as locally acquired in KwaZulu-Natal in 2000,

NKZN2003 = number of cases in KwaZulu-Natal (KZN) in 12 months ending 30 June 2003, etc.

The expected average annual number of cases from 2003 to 2012, Nexpected if all malaria control waswithdrawn would therefore be:

Nexpected = (Nobserved, 2003–2012/(1-Average Effectiveness2003–2012)) ÷10

where Nobserved, 2003–2012 is the recorded number of local cases for the decade 2003–2012.

The same method was used to calculate theexpected number of cases for each year forMpumalanga and Limpopo, assuming effectiveness

to be the same as in KwaZulu-Natal. The casesaverted are the difference between expected andobserved cases (see Figure 19).

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

56

Figure 19Projected number of malaria cases averted annually through IRS, case management andregional control, South Africa, 2003–2012Malaria control averted on average 165 000 cases per annum. Average effectiveness of malaria control inKwaZulu-Natal over the decade can then be estimated at 97% when compared with the 2000 experience.

Cases observed(2012)

Cases expected annually(average from 2003 to 2012) Cases averted annually

KwaZulu-Natal 567 21 857 21 290

Mpumalanga 1207 46 572 45 365

Limpopo 2631 101 497 98 866

Total 4405 169 926 165 521

Note: For the exercise, the year starts on 1 July and ends on 30 June. Cases assessed are locally acquired only and thisevaluation does not factor in population growth.

The total annual budget spent by the NationalDepartment of Health and the three provincialmalaria control programmes is approximatelyUS$ 25 million. This includes treatment costs, andsince effective treatment contributes to prevention,it is not feasible to quantify the exact cost ofprevention.

Accordingly, using the total budget as the upperlimit, an estimate of crude cost per case avertedwould have an upper bound of about US$ 150per annum.

Malaria control has clearly had a major impacton disease burden, and economic and socialdevelopment in the malaria-endemic provincesof South Africa. Areas that would not have beenaccessible for tourism are now promoted as havingan extremely low malaria risk, and other sectors ofthe economy haýe also ÿourished in these areas.The estimate of average annual cases averted, aspresented in this analysis, needs to be interpretedwith caution due to the methodological limitationsdiscussed below, but they nevertheless present areasonable quantiþcation of the beneþt of malariacontrol in South Africa, comparing a period with

limited effective control with a period with all threekey elements of control in operation.

Limitations

• It is impossible to say at what level the KwaZulu-Natal epidemic would have stabilized had it goneunchecked. In our calculation, the estimateof number of cases is conserýatiýe; had theepidemic escalated further, the number of casesaverted would have been larger.

• Malaria control generally has a cumulative long-term effect oýer many years. It is difþcult toquantify this adequately since there is no suitablecontrol group. Our approach has been to usethe same population during an epidemic causedby control failure rather than by meteorologicalfactors, as a comparison; a population case-control design. This is vulnerable to confoundingby secular trends such as cyclical weatherpatterns, socioeconomic development andmigration.

• The effectiveness of the package of interventionsin KwaZulu-Natal would almost certainly not be

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

57


identical in the two other provinces. Insecticidesusceptibility, drug resistance, the impactof malaria control in neighbouring countries(particularly Swaziland and Mozambique),housing types and cultural differences would allhave a differential effect on actual effectiveness.

• A number of malaria cases from endemic areasin South Africa are reported in non-endemicprovinces, or in cities such as Durban. These

have not been included in the calculations, sincetheir origin is often unknown.

• A large number of malaria cases from endemicproýinces are listed as unclassiþed, their originunknown; it is not known whether they areimported or locally acquired. The estimates inFigure 19 have been done excluding these cases,to provide a conservative estimate of impact.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

58

Box 5: Malaria surveillance and response: the crux of a strongelimination programme

The broad objectives of the national malariaelimination strategy inýolýe: strengthening casesurýeillance; capacity deýelopment to facilitateeffectiýe implementation of interýentions; rollingout effective IEC, social mobilization and advocacyprogrammes; preýenting infections; and eliminatingthe parasite reservoir by 2018.

Key issues in the scaling up of monitoring andsurýeillance under the elimination campaign include:reporting passiýe cases within 24 hours; inýestigatingpassiýe cases within 48 hours; rapid reactiýe casedetection and treatment in communities surroundingpassiýe notiþcations; identifying foci of localtransmission typiþed by local case episodes coupledwith the presence of suitable ýector population;and mapping cases, hotspots, transmission foci andoutbreaks. Informed, targeted and timely responsefor case management, community mobilization andvector control depends critically upon such systemsand data.

Description of the malaria surveillancesystem

Four surveillance activities are conducted inSouth African endemic areas: passiýe, actiýe,proactive and outbreak surveillance.

During the passive surveillance process,patients visit health facilities and, once they areparasitologically diagnosed with malaria, thehealth worker notiþes the case on the prescribednotiþcation form and reports traýel history.The programme works towards classifying casesat health-facility level in order to prevent situationswhere patients cannot be traced. This way, thepossible source of infection is identiþed before a caseis traced or a patient is visited at his/her residence.

Health facilities in malaria risk areas are visited twicea week during high transmission periods to ensurethat i) all notiþcations are collected, ii) the availabilityof drugs is monitored and iii) notiþcation forms arecompleted correctly with good quality addresses fortracing patients.

The active surveillance process involves investigatingeach notiþed malaria case and identifying newinfections and potential sources of infection withinat-risk communities (also referred to as activecase ‘inýestigation and detection’). As illustrated inFigure 20, the investigator visits the patient at homeusing the address reported on the notiþcation form.If thepatientcannotbe located, thecase isuntraceableandreportedasunclassiþed.Whenthepatient isfound,the investigator will i) ýerify the case classiþcation,ii) detect possible parasite carriers in the communityand iii) þnd and treat possible malaria breeding sitesusing vector control activities. These actions ensurethat both mosquito vector and parasite loads arereduced within the community. The case investigatorwill also provide health education and test closecontacts. As it is not cost-effective to screenhouseholds within a 2 km radius from an ‘index’case, provincial malaria programmes screen10–20 households in the ýicinity of an identiþedcase. Symptomatic patients in this area are testedfor malaria using RDTs, and blood smears forconþrmation, while asymptomatic people arescreened using blood smears only (see Figure 21).All positives are treated, after referral to the nearesthealth facility when symptomatic. The cases are thenreported to the investigator, with investigation anddetection actiýities starting again from the new ‘index’cases. With limited resources, the programme is alsodoing the 28-day follow-up blood smear collectionto conþrm parasite clearance. This actiýity will beexpanded when resources permit.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

59


Figure 20Active case investigation and detection at facility level

Positive casediagnosed athealth facility

Case notificationform completedat health facility

Case investigatorcollects

notification form

Health education

Contact testing

Vector control

Verify caseinformation

Case investigation Unable to locatethe index patient

Mark untraceable

Primary healthcare process

Malaria controlprogramme process

Locate theindex patient

Source: NDOH, 2013.

Figure 21Active case investigation and detection at community level

Case investigator

Locate theindex patient Contact testing

Symptomatic(RDT + blood

smear confirmation)

Transportto health facility

Asymptomatic(blood smear)

( + ) Test ( + ) Test

Source: NDOH, 2013.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

60

The aim of active surveillance is to preventonward malaria transmission, with reportingbeing done as follows:

- the case investigator collects the notificationform from the health facility and checkswhether all relevant data are collected. Theform should be collected within 24 hours afteridentification of a malaria case (measures arebeing put in place to meet this requirement);

- the investigator starts the follow-upprocedures at the patient’s home within24 hours after notification of the case,and the full report, including informationon entomological surveillance, should besubmitted 48 hours later. This is sometimeschallenging, especially when the number ofcases is significant or resources are limited;

- if a positive case is detected while screening,the case investigator records the data onthe case investigation form, which is thenreported to the nearest health facility.The case investigator then completes thenotification form for this new case, and thepatient is transported to the nearest healthfacility. The community nurse provides thetreatment, and the drugs dispensed to thepatient are documented;

- the environmental health practitioner collectsthe form, and the information is passed to thedistrict manager, who analyses it and thensends the form to the information officer tocollate and verify.

Proactive surveillance is triggered by the strongsuspicion of malaria transmission within a definedarea and/or among community members, migrantworkers or travellers and is undertaken in orderto i) find symptomatic and asymptomatic casesand ii) treat according to national malariatreatment guidelines. Implemented in someidentified localities of Bushbuckridge municipalityin 2012–2013, this process involves the followingactions:

- a case investigator is allocated to a catchmentarea with a number of households to visitregularly;

- screening is undertaken if someone in thehousehold has travelled to a malaria-endemicarea or presents with malaria signs andsymptoms;

- when an infection is identiþed by RDT, thecase investigator informs the community staffnurse and he/she will visit the patient at homeand proýide treatment. The notiþcation formis completed and a blood smear is taken toconþrm and report the malaria case;

- the case investigator screens people living inthe same area having travelled to an endemicarea or presenting the signs and symptoms ofmalaria;

- when a positive case is detected with an RDT,a blood smear is also done and sent to thelaboratory for conþrmation while the patientreceiýes treatment;

- the case investigation form is completedand sent to the health facility in order for thenotiþcation form to be completed;

- the environmental health practitioner collectsthe notiþcation form and forwards it to thedistrict malaria manager, who then sends it tothe information ofþcer;

- the entomological surveillance team checksthe homestead for vectors and their larvae, andcollects information on IRS. If vectors are foundin the vicinity, IRS or larviciding is conducted.

The outbreak surveillance process involvesplanning for outbreaks annually and trackingindicators reported in a checklist. In order todetect outbreaks early, malaria alert thresholds arecalculated at þýe different leýels and monitored byvarious people, from health professionals to malariastaff and information specialists. With this systemin place, the programme has not experienced anymalaria outbreak since 2004/2005.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

61


Methodology for case notiÿcation

Malaria has been a notiþable disease inSouth Africa since 1956, making malaria casenotiþcation mandatory. The process for notifyingcases inýolýes the following steps:

• a notiþcation form (Form GW/17) is completedby the health worker at the health facility, andcollected by the case investigator for follow-upof the patient;

• within 24 hours, the environmental healthpractitioner sends the notiþcation form to thedistrict ofþcer, to inform him/her about each case;

• the data are captured at the district level andsent to the information ofþcer at the proýincialleýel by telephone, fax or email;

• the information ofþcer collates data for allhealth facilities, districts and subdistricts(municipalities), and reports to the provincialmanager on a weekly basis.

Provincial malaria surveillance teams

There are dedicated teams of malaria surveillanceofþcers and case inýestigators working between thehealth facilities and the communities on a daily basis.These teams are led by supervisors dedicated toACD, and consist of case investigation, entomologyand microscopy teams. Provincial surveillanceteams vary in structure and staff number dependingon the size of the malaria transmission area. Atypical malaria case investigation team includes acase investigator, an assistant case investigator, anentomologist/þeld assistant and an enýironmentalhealth practitioner for supervision. The duties ofthe malaria surveillance teams include conductingmalaria-related health education, taking bloodsmears, collecting malaria-related data in the þeld,and assisting the team leaders in conducting case

investigation. Mpumalanga has 12 case investigationteams, 2 entomological teams and 2 microscopyteams. KwaZulu-Natal has 26 teams consisting of191 malaria surveillance agents, and 3 microscopyteams with a total of 10 microscopists. Limpopo has42 IRS teams, 11 dedicated surveillance teams and3 entomology teams.

Case investigation and notiÿcation atnational level

In order to obtain strong surýeillance data, speciþctraining is required for health workers for propercompletion of notiþcation forms, and for inýestigatorsfor adequate inýestigation and classiþcation.In parallel, the programme needs to ensure that dataþelds collected will enable effectiýe monitoring. Datacaptured accurately and timely are prerequisitesfor a clear picture of the disease burden, but alsoto reveal malaria trend lines, monitor all malariaactivities and make informed decisions aboutinterventions to deploy.

The patient’s detailed traýel history beforedeveloping signs and symptoms is captured athealth-facility level from either the patient or arelative. This enables the programme to determinethe probable place of infection, which is critical tothe success of the malaria elimination programme.As presented in Figure 22, investigation activitiesyielded 1828 local malaria cases in 2012, down by18% compared with 2011 levels (2235 cases). At thesame time, the proportion of unclassiþed casesamong all investigated cases decreased markedly,from 13% in 2011 to 5% in 2012, which is testimonyto a good surveillance system.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

62

Figure 22Investigated cases of malaria among all provinces of South Africa, 2011 and 2012Both local and imported cases have decreased between 2011 and 2012. Imported cases, down by 24%compared with 2011, remain a problem because they represent a major threat of potential outbreaks.

Source: NDOH, 2013.

Local cases Imported casesUnclassified cases

0

2000

4000

6000

8000

10 000

12 000

2011 2012

Number of cases

Mpumalanga sets new standards forcase classiÿcation

The Mpumalanga malaria programme focuses onroutine and systematic collection of malaria data,and on their analysis/interpretation, in order tomonitor and describe the disease burden in theprovince. The province submits weekly reportson all malaria cases notified, with a breakdown

of the sources of infection, and details of thestatus of investigation of each case.

The investigation efforts undertaken arecommendable: in the past two years of reportingon confirmed local cases and cases of unknownorigin, Mpumalanga is the only endemic provincethat has not reported unknown/unclassifiedmalaria cases (see Figure 23).

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

63


Figure 23Proportion of local, unclassified and imported cases, malaria-endemic provinces, 2011–2012With more than 6000 confirmed malaria cases recorded between 2011 and 2012, Mpumalanga bears thehighest disease burden. All cases were, however, classified in this province, compared with unclassifiedrates of 24% (n=1294) and 31% (n=334) in Limpopo and KwaZulu-Natal provinces respectively.

Source: NDOH, 2013.

0

1000

2000

3000

4000

5000

6000

7000

Limpopo Mpumalanga KwaZulu-Natal

Number of cases

Local cases Imported casesUnclassified cases

New technologies for surveillance

One of the key requirements for elimination is theneed for rapid case notiþcation and response. Inthis regard, South Africa has been piloting the useof cellular phone technology in parts of Limpopoand Mpumalanga proýinces. The þndings will informthe scale-up of this technology to other malaria-endemic provinces in order to reach the 100% targetfor notifying malaria cases within 24 hours.

The national malaria programme is developing amalaria management information system to ensurethat all elimination indicators are collected andtracked. The key data points within this system willinclude vector control and entomological data, case-based surveillance data, and malaria commodityinformation (ACTs and RDTs).

The 2013 version of the South African malariarisk map was produced using GIS technology,

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

64

with malaria incidence mapped using three-yearsource locality data. Mapping of transmission fociis the next step and this will be pursued using thesame technology.

The South African malaria programme isconsidering using cellular phone technologies,linked to its malaria management informationsystems and its GIS platform, for earlyidentification of malaria outbreaks and responsewithin 72 hours.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

65

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

66

CHAPTER IV

PAVING THE WAY TOWARDS MALARIAELIMINATIONWith eþective malaria control and continued socioeconomic improvements, South Africahas made great strides in reducing morbidity and mortality between 2000 and 2012. Yet themalaria programme realizes the need to address key challenges on the way to eliminatingthe disease – strengthening its human resource capacity and improving surveillance – and toaccelerate eþorts towards this objective. This chapter details the key transitioning activitiesthe programme will have to tackle in the short term.

Paving the way towards malaria elimination at a glance

• South Africa has achieved an incidence of less than 1 malaria case per 1000 population atrisk in its nine malaria-endemic districts.

• The programme needs to focus on strengthening human resource capacity, mobilizing andsustaining þnancing for malaria elimination.

• Operational research is needed to continue reþning the deliýery of eýidence-basedinterventions.

• Malaria transmission foci/hot spots need to be identiþed and a more robust surýeillancesystem must be in place.

Malaria elimination is the next step after effectivemalaria control has been achieved. Effective,well-structured, sustainable control strategieshave resulted in marked reductions in the malariaburden, to the extent that the malaria incidence inSouth Africa is less than 1 case per 1000 populationat risk in its nine malaria-endemic districts.

Poised on the brink of elimination, South Africaneeds to urgently address the challenges in themalaria control programme and to reinforce areasof weakness.

• There is inadequate human capacity at all levels toensure efþcient utilization of resources aýailablefor scaling up malaria control interventions.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

67

| PAVING THE WAY TOWARDS MALARIA ELIMINATION |

The labour-intensive preventive and curativeapproach to malaria control relies heavily on itshuman resource component for implementation.Information systems that have been developedfor use in South Africa are not being utilizedto their full potential due to the lack ofappropriately qualified staff at the national andprovincial level. Malaria control personnel needto be appropriately trained, namely:- spray operators for indoor residual spraying;- health-care staff to ensure correct diagnosis

and effectiýe use of ACTs;- professional entomologists and epidemiologists

trained to conduct essential surveillanceactivities to guide malaria vector control efforts.

• Where feasible, malaria preventive and curativeservices should be integrated within primaryhealth care programmes to ensure sustainabilityof malaria services. In the prevention area, thecountry will also have to explore the provisionof malaria prophylaxis in the public sector.

• As it charts its way towards elimination, theprogramme will also need to implement qualitycontrol and assurance programmes for rapiddiagnostic testing and microscopy. Routinedata collection is required to track the deliveryand usage of diagnostic tests and ACTs.

• The high volume human migration acrossSouth Africa’s northern and eastern bordersplaces a continuing risk of imported malaria onnon-immune border populations. The countrywill work towards making ACTs more accessibleto migrants and communities through malariafield workers.

• There is a lack of key programmatic information(such as reporting on where and when RDTsand ACTs are used) vital for guiding andstrengthening the programme. It should becollected as soon as possible; operationalresearch should help address this challenge.

• All outbreaks need to be investigated withinthree days of detection in order to respond timelyand effectively to an outbreak. The national malariaprogramme needs to work with key stakeholdersto establish more accurate predictions of outbreakand epidemic hotspots (areas of higher thanaverage malaria transmission) in all nine malaria-endemic districts, based on entomological andepidemiological surveillance.

• South Africa will need to strengthen itssurveillance system so that malaria cases arereported within 24 hours, ýeriþed within 48 hoursand responded to within 72 hours.

• Reaching zero local malaria transmission willrequire þnancial resources that will need to besustained after elimination is achieved to preventthe reintroduction of malaria to South Africa.Malaria elimination activities are dependent onan increased annual budget. These funds shouldnot be dependent on donor funding, but shouldcontinue to be part of the national budget.

• Malaria elimination in South Africa is onlypossible if elimination is also successful inneighbouring countries, particularly Mozambiqueand Zimbabwe. Therefore, cross-border malariacontrol with neighbouring countries is essential.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

68

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

69

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

70

CHAPTER V

CONCLUSION

Over the past decade, through evidence-basedstrategies and largely using its own resources,South Africa has intensiþed its malaria controlefforts to the extent that the country has now seta national goal of malaria elimination. Consideringthe extent of the malaria outbreaks of 1999/2000,the achievements have been noteworthy, enablingSouth Africa to set itself the objective of interruptinglocal transmission by 2018.

Lessons for other countries that have embarked onthis same agenda include the value of sustaining

high coverage of vector control interventionsaccording to the country’s epidemiologicalsituation, and decentralizing the implementation ofmalaria control activities and budgets.

To achieve the vision of a malaria-free South Africa,and even of a malaria-free southern Africa, thecountry will strive to maintain adequate human andþnancial resources. At the same time it will needto sustain effective and long-term malaria controlcollaborations with neighbouring countries andstrengthen operational research and surveillance.

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

71

ANNEXList of National Malaria Control Programme PartnersA variety of stakeholders joined the NMCP in implementing the activities and achieving the results describedin this report. These stakeholders include:

National Partners• Department for Correctional Services (DCS)• Department of Agriculture, Forestry and Fisheries

(DAFF)• Department of Environmental Affairs (DEA)• Department of Tourism• Department of Water Affairs (DWA)• National Health Laboratory Service (NHLS)• National Institute for Communicable Diseases

(NICD)• South African Medical Research Council (MRC)• South African Military Health Service (SAMHS)• South African Regional Global Diseases

Detection Program (SARGDD)• University of Cape Town (UCT)• University of Pretoria (UP)• University of the Witwatersrand (Wits University)

International Partners• Africa Fighting Malaria (AFM)• African Medical and Research Foundation

(AMREF)• Clinton Health Access Initiative (CHAI)• GBCHealth• Johns Hopkins Uniýersity (JHU)• Roll Back Malaria Partnership (RBM)• Southern Africa Roll Back Malaria Network

(SARN)• Southern African Development Community

(SADC)• United Against Malaria (UAM)• United Nations Children’s Fund (UNICEF)• World Health Organization (WHO)

FOCU

SON

SOUT

HAF

RICA

PROG

RESS

&IM

PACT

SERI

ES

72

Secretariat hosted by the World Health Organization

Avenue Appia 20, 1211 Geneva 27, Switzerland www.rollbackmalaria.org [email protected] Tel. +41 22 791 5869 Fax +41 22 791 1587

progress & impact series -...

Documents